Methods for closing the left atrial appendage

ABSTRACT

Described here are devices, systems and methods for closing the left atrial appendage. Some of the methods described here utilize one or more guide members having alignment members to aid in positioning of a closure device. In general, these methods include advancing a first guide having a first alignment member into the left atrial appendage, advancing a second guide, having a second alignment member, into the pericardial space, aligning the first and second alignment members, advancing a left atrial appendage closure device into the pericardial space and adjacent to the left atrial appendage, and closing the left atrial appendage with the closure device. In these variations, the closure device typically has an elongate body having a proximal end and a distal end, and a closure element at least partially housed within the elongate body. The closure element comprises a loop defining a continuous aperture therethrough.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. patent application Ser. No.14/625,540, filed on Feb. 18, 2015, which issued as U.S. Pat. No.10,966,725 on Apr. 6, 2021, and which is a continuation of U.S. patentapplication Ser. No. 12/363,381, filed on Jan. 30, 2009, which issued asU.S. Pat. No. 8,986,325 on Mar. 24, 2015, and which is a continuation ofU.S. patent application Ser. No. 12/055,213, filed on Mar. 25, 2008,which issued as U.S. Pat. No. 8,771,297 on Jul. 8, 2014, and whichclaims priority to U.S. Provisional Patent Application Ser. No.60/921,002, filed on Mar. 30, 2007, each of which is incorporated hereinby reference in its entirety.

FIELD

In general, the devices, systems, and methods described here are forclosing off a portion of tissue, e.g., the left atrial appendage, usinga surgical, minimally invasive, or intravascular approach.

BACKGROUND

Atrial fibrillation is a common problem that afflicts millions ofpatients. Unfortunately, atrial fibrillation often results in theformation of a thrombus, or clot, in the appendage of the left atrium.This presents a problem, inasmuch as the thrombus can dislodge andembolize to distant organs, resulting in adverse events such as astroke. For this reason, most patients with atrial fibrillation aretreated with a blood thinner to help prevent the formation of athrombus. Blood thinners, however, can present health risks (e.g.,bleeding), particularly in the elderly, and often also require that theuser make significant lifestyle changes.

Several methods have been developed to address the potential problem ofthrombus formation in the left atrial appendage. One such method issuturing along the base, or ostial neck of the appendage, where it joinsthe atrial chamber. In this way, blood flow into the atrial appendage iscut-off, eliminating the risk of thrombus formation therein. This istypically done through open-heart surgery, making the availability ofthe procedure available to only those who are otherwise undergoing anopen-heart procedure, or who are at particularly high risk. In addition,open-heart surgery requires general anesthesia and has a number ofwell-know risks, making it less desirable.

Other methods have also been investigated. For example, methods ofstapling the base of the appendage and methods have been investigated,as have methods of filling the appendage with a space occupying, oroccluding member. However, stapling is not a preferred method given thefragility of the appendage and the likelihood of its rupture. Occlusiondevices may not effectively prevent all blood flow into the appendage,leaving areas of potential thrombus formation.

Additional devices and methods for closing the left atrial appendagewould therefore be desirable. In particular, devices and methods forclosing the left atrial appendage using minimally invasive,intravascular, or a combination of these techniques, would be desirablein order to avoid the need for opening the chest. Of course, additionaldevices for use in open surgical procedures are desirable as well,especially when those devices offer additional advantages over standarddevices.

BRIEF SUMMARY

Described here are devices, systems and methods for closing the leftatrial appendage. Some of the methods described here utilize one or moreguide members having alignment members to aid in positioning of aclosure device. In general, these methods comprise advancing a firstguide having a first alignment member into the left atrial appendage,advancing a second guide, having a second alignment member, into thepericardial space, aligning the first and second alignment members,advancing a left atrial appendage closure device into the pericardialspace and adjacent to the left atrial appendage, and closing the leftatrial appendage with the closure device. In these variations, theclosure device typically comprises an elongate body having a proximalend and a distal end, and a closure element at least partially housedwithin the elongate body. The closure element comprises a loop defininga continuous aperture therethrough.

Any of the devices used in any of the methods described here may beadvanced under any of a variety of visualization techniques, e.g.,fluoroscopic visualization, ultrasound, etc. For example, the firstguide, second guide, or both guides may be advanced under fluoroscopicvisualization in some variations. Similarly, any of the devices used inany of the methods described here may be advanced over a guide elementor guide wire. For example, the first guide, second guide, closuredevice, any additional guide, or any combination thereof, may beadvanced over a guidewire. In some variations, the second guide iscoupled to the closure device for at least a portion of the method.

The alignment members may be, or may comprise, any suitable alignmentmember. For example, they may be or may comprise magnets, radiopaquemarkers, echogenic markings, members configured to produce one or moreaudible signals, interconnecting or interlocking members, one or morevacuum members, or the like. In some variations, the alignment membersare magnets.

The first guide may further comprise an expandable member, e.g., anexpandable cage, an expandable strutted structure, an expandableballoon, or the like. In some variations, the expandable membercomprises an expandable balloon. The expandable member may be used forany suitable purpose, e.g., to atraumatically displace tissue, to helpwith identifying, sizing, protecting, isolating, stabilizing, orpositioning tissue, or the like. In some variations, the expandablemember is expanded within the left atrial appendage. In other variationsof the methods described here, a third guide is advanced into the leftatrial appendage, where the third guide has a proximal end and a distalend and comprises an expandable member. In some additional variations,the first and third guides are coupled together for at least a portionof the method. Again, the expandable member may comprise any suitableexpandable member. In some variations, the expandable member is aballoon, which may or may not have one or more apertures therein. Theapertures, for example, may be useful in enabling inflation anddeflation of the balloon, may be useful for enabling passage of one ormore guides or guidewires therethrough, or may be useful in enablingdelivery of fluids, such as saline, contrast, drugs, etc., distal of theballoon.

The closure device may further comprise a suture for encircling the leftatrial appendage after it has been closed with the closure device. Ofcourse, the closure device may also have the ability to encircle theleft atrial appendage without having a suture coupled thereto. Theclosure element alone may capture and release the left atrial appendage(i.e., it can open and close around the left atrial appendage), whichmay help facilitate optimal closure of the left atrial appendage, priorto permanent exclusion. In some variations, where a suture is used, thesuture may comprise a surgical slip knot. The suture may or may not becoupled to the closure element.

The methods described here may further comprise tensioning the suture.The methods may additionally comprise releasing the tension on thesuture, e.g., to help facilitate repositioning of the device, and thelike. The methods may further comprise releasing the suture from theclosure element, tightening the suture, and severing the suture. Whenthe methods include severing the suture, the suture may be severed inany suitable fashion. For example, the suture may be severed with acutting, element, or may be severed by the application of energy (e.g.,light energy, thermal energy, RF energy, electrical energy, magneticenergy, electromagnetic energy, kinetic energy, chemical energy andcombinations thereof). When a cutting element is used, it may be anelement on the closure device itself, or it may be part of a separatedevice.

The methods described here may also include confirming satisfactory oroptimal closure of the left atrial appendage prior to permanentexclusion, excluding or opening the left atrial appendage with theclosure device, repositioning the closure device, reclosing the leftatrial appendage, and permanently excluding the left atrial appendage.

Other methods for closing the left atrial appendage are also described.In these methods, a closure device is advanced into the pericardialspace and adjacent to the left atrial appendage, the left atrialappendage is closed with the closure device, the left atrial appendageis secured with a suture, and then the suture is severed. In thesevariations, the closure device typically comprises an elongate bodyhaving a proximal end and a distal end, and a closure element thatcomprises a loop defining a continuous aperture therethrough.

As with the methods described just above, the severing of the suture maybe accomplished in any suitable fashion. For example, the suture may besevered with a cutting element, or by the application of energy (e.g.,light energy, thermal energy, RF energy, electrical energy, magneticenergy, electromagnetic energy, kinetic energy, chemical energy andcombinations thereof). When a cutting element is used, it may be anelement on the closure device itself, or may be part of a separatedevice, or some combination of both may be used.

The closure device may comprise one or more expandable elements, and theclosure device, the suture, or both may comprise a radiopaque material,echogenic material, or some combination thereof. In some variations, theclosure device is made from a shape-memory material (e.g., a nickeltitanium alloy, or the like), and in some variations, the suture iscoupled to the closure device. In these methods, the closure device maybe visualized while advanced, e.g., using fluoroscopy, ultrasound, acombination thereof, etc., and may or may not be advanced over a guideelement or guidewire.

Additional methods for closing a left atrial appendage are alsodescribed here. These methods typically comprise advancing a first guidehaving a proximal end and a distal end into the left atrial appendage,through the left atrial appendage, and out of the left atrial appendage,such that one of the proximal or distal ends is within the vasculature,and one of the proximal or distal ends is within a subthoracic space,and advancing a left atrial appendage closure device into thepericardial space and adjacent to the left atrial appendage, and closingthe left atrial appendage with the closure device. In these methods, theclosure device typically comprises an elongate body having a proximalend and a distal end, and a closure element housed within the elongatebody, where the closure element comprises a loop defining a continuousaperture therethrough.

In these methods, the proximal end of the first guide may be within thevasculature, or within the stubthoracic space. In some variations, theclosure device is advanced into the pericardial space over the firstguide. Again, as with all the methods described here, any of the devicesmay be advanced under any of a variety of visualization techniques. Forexample, the first guide, closure device, or both may be advanced underfluoroscopic or ultrasound visualization, or both. In some variations,the methods further comprise advancing a second guide into the leftatrial appendage, where the second guide has a. proximal end, a distalend, and comprises an expandable member. The expandable member may beany suitable expandable member (e.g., expandable struts, expandablecage, expandable balloon, or the like). In some variations, the firstand second guides are coupled together for at least a portion of themethod.

Devices for closing the left atrial appendage are also described here.Some of the devices described here comprise an elongate body having aproximal end and a distal end, a closure element comprising a loopdefining a continuous aperture therethrough at least partially housedwithin the elongate body, and a suture loop. The suture loop may or maynot be coupled to the closure element. For example, the device mayfurther comprise a retention member, where the retention member isconfigured to retain the closure element and the suture loop. Theretention member may be configured to accomplish, this task in anysuitable fashion. For example, it may comprise first and second lumens,where the closure element is housed within the first lumen and thesuture loop is housed within the second lumen. The second lumen may havea weakened region, a perforated region, or a slit or other openingconfigured to release and/or close the suture with the application of aforce. in other variations, the retention member and the closure elementare withdrawn or otherwise removed, leaving behind and/or closing thesuture loop. In still other variations, the retention member comprises afirst lumen and one or more releasable retention elements, where theclosure element is housed within the first lumen and the suture loop isretained by the one or more releasable retention elements. The retentionelement may be any suitable element, for example, a releasable prong, apolymer tack, and the like.

The closure element may be made from any suitable material. In somevariations, the closure element is made from a shape-memory material(e.g., a nickel titanium alloy). Similarly, the suture loop may be madefrom any suitable material (e.g., any suitable material useful forexclusion or closure). It may be bioabsorbable (e.g., biodegradablepolymers, etc.), or non-bioabsorbable (e.g., non-biodegradable polymers,metals, etc.). The closure element, suture loop, or both may comprise aradiopaque or echogenic material.

In some variations, the elongate body has one or more curves along itslength. The elongate body may or may not be steerable, and may or maynot be configured as a catheter. In some variations, the closure elementand the suture loop are separately actuatable. In other variations, thedevice further comprises a cutting element.

Systems for closing a left atrial appendage are also described here.Typically, the systems comprise a first guide having a size and lengthadapted for accessing the left atrial appendage through the vasculature,where the first guide comprises a first alignment member, a second guidehaving a size and length adapted for accessing the pericardial spacefrom a subthoracic region, where the second guide comprises a secondalignment member, and a closure device comprising an elongate bodyhaving a proximal end and a distal end, and a closure element housed atleast partially therein, where the closure element comprises a loopdefining a continuous aperture therethrough. The system may furthercomprise any suitable or useful device or component.

For example, in some variations the system further comprises anexpandable member. The expandable member may be any suitable expandablemember, and in some variations the expandable member is an expandableballoon with or without one or more apertures therein. The expandablemember may be configured to be couplable to the first guide.

The systems described here may further comprise a suture, which may ormay not be coupled to, or couplable with, the closure device. Thesystems may also comprise a device or element for severing the suture.In some variations, the closure device is couplable to the second guide.

The first and second alignment members may be any suitable alignmentmembers. For example, they may be or may comprise magnets, radiopaquemarkers, echogenic markings, members configured to produce one or moreaudible signals, interconnecting or interlocking members, one or morevacuum members, or the like. In some variations, the alignment membersare magnets, which may or may not be located at the distal ends of thefirst and second guides. The systems may further comprise instructionsfor using the first guide, second guide, closure device, or anycombination thereof. In some variations, the elongate body of theclosure device has one or more curves along its length, and the systemsfurther comprise a straightening tube, configured to temporarilystraighten the one or more curves.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 provides a cross-sectional representation of a heart showingvarious anatomical structures.

FIGS. 2A-2B are different views of an illustrative device that may beused with the systems and methods described herein.

FIG. 3A provides a close-up view of a distal end of an illustrativedevice having a retention member.

FIGS. 3B-3D depict illustrative retention members that may be used withthe devices described herein.

FIG. 4 provides a close-up view of a distal end of a illustrativedevice, without a retention member.

FIG. 5 is a depiction of an illustrative device with the catheter bodyremoved for purposes of description and clarity.

FIG. 6 provides another depiction of an illustrative device with thecatheter body removed, here, showing more of the device.

FIG. 7 is a close-up view of an illustrative suture retention mechanism,here, shown. as a suture hook.

FIG. 8 is a close-up view of a distal end of an illustrative devicehaving a lumen therethrough.

FIG. 9 is a top side view of one variation of the proximal end of thedevices described here.

FIG. 10 is a skewed end view of one variation of the proximal end of thedevices described here.

FIG. 11 provides a cross-sectional view of one variation of the proximalend of the devices described here.

FIG. 12 is an illustrative suture cutter that may be used with thesystems and methods described here.

FIGS. 13A and 13B are illustrative guides having alignment members.

FIGS. 14A-14D depict an illustrative method of closing the left atrialappendage.

FIGS. 15A-15D depict an alternative illustrative method of closing theleft atrial appendage.

FIG. 15E depicts an illustrative device that may be used to perform themethod depicted in FIGS. 15A-15D.

DETAILED DESCRIPTION

Described here are devices, systems, and methods for closing the leftatrial appendage. In this regard, it may be helpful to start by brieflyidentifying and describing the relevant heart anatomy. Shown in FIG. 1is a cross-sectional view of the heart (100). Shown there is left atrium(102) and left ventricle (104). In between the left atrium (102) and theleft ventricle (104) is the mitral valve (also known as the bicuspidvalve), which is defined by a pair of mitral valve leaflets (106). Theleaflets are connected to chordae tendinae (108) that are in turn,connected to papillary muscles (110). The papillary muscles joinventricular wall (112). The left atrial appendage (114) is shownadjacent to, and is formed from, the wall of the left atrium (102).

As can be seen, the left atrial appendage (114) lies within theboundaries of the pericardium (116), and is in close proximity to theventricular wall (112). The left atrial appendage typically has atubular shape that approximates a cone, with a slight narrowing or neckin the plane of the orifice where it joins the left atrium (102). Inpatients with atrial fibrillation, the left atrial appendage (114) isthe most common location for thrombosis formation, which, in time, maydislodge and cause a devastating stroke. Because stroke is the primarycomplication of atrial fibrillation, the left atrial appendage isfrequently excluded from the left atrium in those patients undergoingprocedures to treat atrial fibrillation, and is often removed orexcluded at the time of other surgical procedures, such as mitral valvesurgery, to reduce the risk of a future stroke. The devices and systemsdescribed here, help ensure proper closure of the left atrial appendage,at the neck or base of the left atrial appendage, along the anatomicostial plane. In this way, exclusion of the entire left atrial appendagefrom systemic circulation may be facilitated.

I. Devices

The devices described here for closing the left atrial appendagegenerally comprise a closure element having one or more loops. Thedevices may be suitable for use with minimally invasive access to theleft atrial appendage (e.g., through a small sub-xyphoid or otherintercostal incision, through an incision in the costal cartilage,through a port, through the vasculature, etc.) or may be suitable foruse with open surgical procedures. The lengths of the devices may bechosen as desirable.

FIGS. 2A and 2B provide different views of an exemplary device that maybe used to close the left atrial appendage. Shown in FIG. 2A is device(200) comprising an elongate body (202) having a proximal end and adistal end, and a closure element (204). In this variation, the closureelement comprises a loop that defines a continuous aperture therethroughsuitable for encircle the left atrial appendage therein. The closureelement is at least partially housed within the elongate body (202) andmay be advanced therefrom, or retracted therein. Also shown in FIG. 2Ais a lumen (214) for passage of a tools or fluids therethrough. Forexample, the lumen (214) may enable passage of a guide (with or withoutan alignment member), a guidewire, a suture cutter, fluids and/or drugs,and the like. Any number of lumens may be used for any suitable purpose.Suitable lumens will be described again with reference to FIG. 8. Alsoshown in FIGS. 2A and 2B is handle (206) having a linear actuation slide(208) and knob (210). Additional details of the handle will be discussedbelow.

In the variation shown in FIGS. 2A and 2B, the elongate body (202)comprises a curve (212) at a distal portion thereof. In instances wherethe elongate body (202) of the device comprises one or more curves, astraightening tube, or other straightening mandrel or mechanism may beused to temporarily straighten the elongate body during delivery (e.g.,until the pericardial space is reached). After a particular location hasbeen reached, the straightening tube or mandrel may then be withdrawn.The straightening tube may be made of any suitable material (e.g., arigid plastic, stainless, combination thereof, etc.). Of course, itshould be understood that the device need not comprise one or morecurves as shown in FIGS. 2A and 2B. For example, the elongate body maybe straight and flexible, and a pre-curved tube or mandrel may beemployed during the methods to aid in delivery and use (e.g., whileadvanced to the left atrial appendage). Similarly, the elongate body maybe straight and flexible, and have a pull wire attached thereto, so thatwhen the pullwire is pulled proximally, the elongate body flexes andbends. In this variation, the elongate body may be maneuvered asappropriate. It should be understood that any of the devices describedhere may be configured for steerability, or may be configured forrobotic use (e.g., configured for use with one or more robotic or otherautomated type device).

FIG. 3A provides additional detail of a suitable closure element. Shownthere is a distal portion (300) of a suitable closure device having anelongate body (302) and a closure element assembly (304). In FIG. 3A,details of an elongate body extension, or tip (306) can be seen. Thistip may be thermoformed or injection molded, or may be integral with therest of the elongate body (302). In instances where a suture loop (308)is used, the tip (306) may serve to house a suture knot therein. Itshould be understood that when reference is made to the elongate body,it is meant to include any such tip (306) as shown in FIG. 3A. Alsoapparent in FIG. 3A is suture loop (308), which is shown passing throughthe tip (306) in a proximal direction and into a retention member (312)in a distal direction. Also shown passing through tip (306) in aproximal direction and into retention member (312) in a distal directionis closure element (310), which will form a loop to encircle the leftatrial appendage. As can be seen by FIG. 3A, the retention member isconfigured to retain the closure element and the suture loop.

FIGS. 3B-3D depict illustrative retention members that may be used withthe devices described herein. FIG. 3B shows an end view of a retentionmember (314) having first and second lumens (316, 318) for retaining aclosure element and a suture loop therein. In this variation, the secondlumen (318) has a slit or other opening (320) along its length, forallowing the suture to pass therethrough when it is ready to bedeployed. Of course, it should be understood that the first and secondlumens may be positioned or oriented in any suitable way with respect toeach other, and similarly, the slit or other opening on the second lumenmay be positioned or oriented in any suitable fashion with respect tothe first lumen (e.g., it may be approximately 180% approximately 150°,approximately 120°, approximately 90°, approximately 60°, approximately30°, or the like, from the first lumen (316)). FIG. 3C provides anillustration of a retention member having a first lumen (322), a secondlumen (324), and a slit (326). In this variation, the slit (326) ispositioned closer to the first lumen (322) than the slit of FIG. 3B. Thewidth or spacing of the slit opening may selected as desired orappropriate. Similarly, the slit need not extend or be continuous alongthe entire length of the retention member. In some variations, the slitsmay have prongs or arms along its length to help capture and retain thesuture therein. In other variations, the slits may be covered at spacedapart locations therealong with a biodegradable polymer, temporarilyused to tack or hold down the suture. Of course, in still othervariations, the retention member does not comprise a slit, and insteadcomprises some other type of retention mechanism, such as the prongs ortacks described just above. In yet other variations, there are no slitsor openings in the retention member and the suture loop is released uponremoving or withdrawing the retention member and closing the device.

FIG. 3D provides another variation of a retention member. In thisvariation, the retention member has a first lumen (328), second lumen(330), and a separation region (332). The separation region may beconstructed in any suitable fashion. For example, the separation regionmay comprise a perforated region adapted to perforate and release thesuture with the application of force. Alternatively, the separationregion may be a thin-walled or other type of weakened region that may beconfigured to break and release the suture. It should be understood thatthe retention member may have any suitable geometry or shape, and may bemade from any suitable material. Similarly, the lumens need not be fullcircles or have a circular cross-sectional geometry. When these or othertypes of retention members are used, the suture loop may be torn out,pulled through, or otherwise released from the retention member after ithas been properly positioned and tightened as desirable.

The above described components may be made of any suitable material. Forexample, the closure element may be made from a shape-memory material,such as a shape-memory alloy (e.g., nickel titanium alloy, etc.), may bemade from stainless steel, polyester, nylon, polyethylene,polypropylene, some combination thereof, etc. Similarly, the suture loopmay be made of any suitable material useful in exclusion or closure, andthe term “suture loop” should be understood accordingly. For example, itmay be made of a biodegradable material (e.g., polylactic acid,polyglycolic acid, polylactic-co-glycolic acid, etc.), or may be made ofa non-biodegradable material (e.g., metal, steel, polyester, nylon,propylene, silk, and combinations thereof). In some variations, as willbe described in more detail below with reference to the methods, thesuture loop is made from a biodegradable material such that the sutureloop degrades after a period of time has elapsed (e.g., for sufficientscarring to be achieved). It should be understood, the any part of thedevice may comprise, include, or be made from a radiopaque or echogenicmaterial to help facilitate visualization. For example, the closureelement, the suture loop, the elongate body, or any combination of thesecomponents may comprise a radiopaque or echogenic material.

The suture loop and the closure element may be configured to have anyappropriate perimeter. For example, they may have a perimeter of 4.5inches in a fully expanded state, a perimeter of about 4.3 inches,about, 3.3 inches, about 4.0 inches, about 3.5 inches, about 3.3 inches,3.0 inches, about 2.7 inches, about 2.5 inches, about 1.5 inches, about1.25 inches, or the like. Of course, these perimeters will vary as theclosure element and suture loop are actuated and retracted.

For additional clarity, FIG. 4 provides a view of distal portion (300)of FIG. 3A, without retention member (312), thus showing the loopednature of closure element (310) and suture (308). FIG. 5 is a view ofdistal portion (300), without retention member (312), tip (306), andelongate body (302), thus providing additional details of this variationof the device. Shown there is of course, closure element (310) andsuture (308). Suture (308) further comprises a surgical knot (e.g., aone way slipknot or other suitable knot) (500). Also shown is ananchoring feature. (502), here shown as a tube, for anchoring one sideof the closure element (310). The opposite side of the closure elementis the active or actuation side (i.e., one side remains anchored whilethe other side has additional active length). Of course, when anchoringis used, it may be done in any suitable way. In other variations (notshown here), both sides of the closure element are active and actuatable(i.e., neither side is anchored). The device may also comprise a suturetube (504) for facilitating suture passage.

FIG. 6 shows additional proximal detail of a suitable closure device. Inthis view, the elongate body and tip have been removed, but theretention member remains. Of particular interest here is suture hook(600). Suture hook (600) captures suture loop (308) so that the closureelement (310) may be advanced and retracted separately from suture loop(308) when the two are coupled together. That is, the suture hook (600)prevents the suture from tightening as the closure element is actuated,so that the device may be positioned as desirable before the suture isactuated. The suture hook (600) may also help prevent excess suture fromopening and closing, and thus help prevent excess suture from gettingcaught on anatomical structures, instruments, etc. Also shown in FIG. 6is a proximal length of the closure element (602). In some variations,it may be useful to have at least a portion of the proximal length ofthe closure element (602) coated with a lubricious coating, in order tohelp facilitate slidable actuation. Any suitable lubricious coating maybe used (e.g., PTFE, etc.). The suture hook (600) is shown in greaterdetail in FIG. 7. While the suture hook shown in FIG. 7 has a roundedatraumatic tip, it need not be so. Indeed, any suitable tip may be used.The suture hook may be made of any suitable material.

FIG. 8 provides details of the distal portion of an illustrative closuredevice (800), here comprising at least one lumen (802) in the elongatebody (804). The lumen may be used for any suitable purpose. For example,it may be used to enable passage of one or more guides or guidewirestherethrough, one or more tools therethrough, or the like. The lumen mayalso be used as a flush lumen, a vacuum lumen, a drug delivery lumen, orthe like. The elongate body may comprise any number of lumens, and itshould be understood that the lumens need not traverse the entire lengthof the elongate body, nor form a completely bounded aperture (i.e., theuse of lumens herein is intended to capture instances where a slit orgroove may be used with one or more guides, guidewires, or additionaltools).

FIG. 9 is one variation of a suitable handle (900) for the devicesdescribed herein. In this variation, the handle comprises a linearactuation slide (902) for actuating the closure element, and a sutureknob (904) for actuating the suture. While not shown, the suture hook,described above, or similar such feature, helps enable the separateactuation capability described here. Thus when the slide (902) is pusheddistally, the closure element, which has been at least partiallyretained within the elongate body, will be advanced distally, and theloop size of the closure element will get bigger. Conversely, when theslide is retracted proximally, the closure element will be retracted andthe loop size will get smaller. The suture loop is not affected in thisprocess. Instead, the suture loop in this variation is controlled by thesuture knob. Of course, the suture loop need not be actuated by a knob.That is, the suture may be separately actuated by an additional slide,lever, button, or the like. Similarly, the closure element need not beactuated by a slide. It may be actuated by a button, knob, lever, or thelike.

Also shown in FIG. 9 is suture cutting slot (906). While not easilyshown in this view, the suture runs through the handle and into theknob. The suture cutting slot enables the suture to be cut easily, asthe suture traverse the slot and the slot provides a viewing window andaccess point for suture severing. Of course, the suture need not besevered in such a fashion. In some variations, the closure device itselfcomprises a cutting element for severing the suture (e.g., a bladeactuated by a button or some other mechanism). FIG. 10 provides a skewedend view of the handle shown in FIG. 9 so that additional details may beseen. Specifically, shown here are suture knob lock (1000) and leerfitting (1002) at the proximal end of the handle lumen.

FIG. 11 provides a cross-sectional view of a portion of handle (1100),here showing a length of the handle including the suture knob (1102) andthe slide actuator (1104) in its most retracted position. Suture knob(1102) comprises an outer knob (1106), and outer knob bearing (1108),inner knob (1110) and inner knob bearing (1112), thrust bearing (1114)and slip clutch plates (1116) that when actuated (when the knob (1102)is turned or rotated) apply a tension upon the suture loop causing it torelease from the retention member. In one variation, the slip clutchplates (1116) have particular force settings and are configured toprovide tactile feedback to the operator indicating closure. In othervariations, the clutch plates (1116) may have a particular forcelimitation in order to protect against shearing or cutting of tissue bythe suture during release or tightening of the suture loop. For example,in these variations, once the suture loop reaches a pre-determinedforce, the outer knob (1106) and outer knob bearing (1108) may disengagefrom inner knob (1110) and inner knob bearing (1112) by slipping or thelike (e.g., similar to a gas cap when overtightened).

Also shown is a suture reel area (1118) and a suture severing slot(1120), which, as described briefly above, is used to help terminate thesuture by placement of blade, scalpel, or other sharp instrumenttherein. As described above, in sonic variations, the closure deviceitself comprises a suture cutting device or mechanism, and this may belocated at the same place as the suture severing slot (1120) or someother place. For example, the device may include a blade or othercutting mechanism that may be actuated by a blade, lever, knob, etc.,whether or not located in the suture severing slot location. Lumen(1122) may be used for placement of a guide (with or without analignment member), guidewire, one or more tools (e.g., a suture cutter,visualization devices, etc.), one or more fluids (e.g., saline, drugs,etc.), as described above.

II. Methods

Methods for closing the left atrial appendage are also described here.The left atrial appendage may be accessed in any suitable fashion, andany of the devices described here may be used. For example, the leftatrial appendage may be accessed from the inside of the heart, or may beaccessed from the outside of the heart. In some variations, the leftatrial appendage is accessed from both the inside of the heart, and theoutside of the heart. Typically, the appendage is closed off from theoutside of the heart, even when accessed from the inside of the heart.

In variations when the left atrial appendage is accessed from both theinside and the outside of the heart, it may be useful to employ the useof guides having alignment members. In this way, accessing the leftatrial appendage may be more easily facilitated. It may also be usefulto employ the use of a positioner or stabilizer, to help positiondevices relative to the left atrial appendage and to stabilize theappendage while it is being closed off. The positioner or stabilizer maybe any suitable stabilizer or positioner, e.g., an expandable member orthe like. More details of this will be described below.

In some variations, the methods of closing the left atrial appendagecomprise advancing a closure device into the pericardial space andadjacent to the left atrial appendage, closing the left atrial appendagewith the closure device, securing the closed left atrial appendage witha suture, and then severing the suture. The closure device may be anysuitable closure device, such as a device having an elongate body with aclosure element comprising a loop defining a continuous aperturetherethrough, as described above. The suture may be severed in anysuitable fashion, and at any suitable location along its length (i.e.,from immediately adjacent to the knot at the left atrial appendage tojust proximal to, or just distal to, the skin surface). In someinstances it may be desirable to sever the suture at the knot itself(e.g., in instances where it is desirable to release tension on thesuture entirely).

An illustrative device (1200) for severing a suture is shown in FIG. 12.The device depicted there may be threaded over the suture and thenactuated to cut the suture with a blade or similar cutting featurehoused within distal portion (1202). While a device having a bladehoused therein is depicted in FIG. 12, any suitable cutting device maybe used, and the device may be made from or comprise any suitablematerials (e.g., a radiopaque or echogenic material). In somevariations, the closure device has a cutting element thereon, forcutting the suture. Of course, the suture need not be severed with ablade or other such cutting feature. The suture can be severed by theapplication of energy. For example, the suture may be severed with theapplication of light energy, thermal energy, RF energy, electricalenergy, magnetic energy, electromagnetic energy, kinetic energy,chemical energy, and combinations of any of the above. Additionalmethods will now be described.

A. Transseptal and Pericardial Access

In some variations, the methods for closing the left atrial appendageinclude accessing the left atrial appendage from both the inside of theheart and the outside of the heart. In these variations, one or moreguides having alignment members are often used to align the inside andoutside access devices together. To access the inside of the heart, thevasculature is typically used. For example, access may be obtained viaone or several of the various veins or arteries (jugular, femoral,carotid, etc.). In some variations, the heart is accessed on the insidevia the common femoral vein (e.g., the left common femoral vein) using astandard Seldinger technique with a needle. An introducer wire may thenbe advanced through the needle, followed by an introducer sheath. Theintroducer wire may then be removed. In some variations, a guidingcatheter sheath may be placed as an alternative to an introducer sheathor the initial sheath may be replaced with a guiding catheter sheath.

Using fluoroscopy, an angiogram performed through the sheath, a catheterplaced through the sheath, a guiding catheter sheath, or any combinationthereof, may be performed to observe anatomical characteristics andconsiderations of the access route for the purpose of transseptal accessinto the left atrium (e.g., tortuosity, clots, devices, such as venacava filters, etc.). Fluoroscopy, ultrasound, intracardiacechocardiography, extracardiac echocardiography, transesophagealechocardiography, or combinations thereof, may be used to help visualizetransseptal access to the left atrium, and access to the left atrium maybe obtained using standard transseptal access techniques.

For access to the heart from the outside, a subthoracic access point maybe used. The access point is typically identified based on patientanatomic characteristics. In some variations, the access point is rightof the xyphoid process and pointed towards the patient's left shoulder,but may be at any suitable location (e.g., intercostal access via asternotomy, thoracostomy, or thoracotomy, or in the costal cartilageitself). Once the access point has been determined, a needle (e.g., a17G Tuohy needle) may be advanced using standard pericardiocentsesistechniques under fluoroscopic guidance. After access to the pericardiumhas been obtained, a guidewire may be advanced through the needle underfluoroscopic visualization within the pericardiac sac. The needle maythen be removed. Access to the pericardial space has thus been obtained.

Turning now to the figures, after access from the inside and outside ofthe heart has been obtained using the above described devices andtechniques, the devices of the current invention are ready for use. Forexample, first (1300) and second (1302) guides having alignment membersas shown in FIGS. 13A and 13B respectively may be used to guide theprocedure. The alignment member may be any suitable alignment member(e.g., interconnecting elements, one or more vacuum members, radiopaqueor echogenic markers, members that are configured to produce an audibleresponse, magnets, etc.). Here, the alignment members are magnets (1304,1306) located at the distal ends of the guides. The magnets may be madefrom or comprise any suitable magnetic material, e.g., a rare earthmagnet, such as neodymium-iron-boron, cobalt-samarium, or other powerfulfixed magnet elements. These guides may be used for guiding additionaltools and/or devices to the left atrial appendage.

The guides may have any suitable lengths and/or dimensions. For example,the guides may have a diameter of about 0.010″ to about 0.050″, about0.020″ to about 0.030″, or the like. In some variations the first guidehas a diameter of about 0.025″ and the second guide has a diameter ofabout 0.035″. Similarly, the length may be any suitable length. Forexample, from about 50 cm to about 300 cm or more, from about 100 cm toabout 200 cm, from about 200 cm to about 250 cm, and the like. In somevariations, the first guide has a length of about 250 cm and the secondguide has a length of about 90 cm. The outer diameter of the alignmentelement may also be selected as desirable. For example, it may be fromabout 0.05″ to about 0.2″ or more. In some variations, the outerdiameter of the alignment member of the first guide is about 0.106″ andthe outer diameter of the alignment member of the second guide is about0.170″. It should be understood that these dimensions are suitable forany guide, not only guides having alignment members comprising one ormore magnets.

For example, turning to FIG. 14A, the first guide (1400) may be advancedinto the left atrial appendage (1404), while the second guide (1402) maybe advanced into the pericardial space adjacent to the left atrialappendage. Either of these guides may be advanced under any of a varietyof visualization techniques, e.g., fluoroscopic visualization,ultrasound visualization, some combination thereof, etc. A ballooncatheter (1406) or other expandable member may be advanced over thefirst guide, or in conjunction with the first guide (e.g., it may becoupled to or be part of the first guide) and into the left atrialappendage as shown in FIG. 14B. Similarly, a closure device (1408) maybe advanced over the second guide, or in conjunction with the secondguide (e.g., it may be coupled to or be part of the second guide), asshown in FIG. 14B.

In instances where a balloon is used as an expandable member, it may bemade of any suitable material. For example, it may be made ofpolyisoprene, or other suitable materials. Similarly, the balloon mayhave any suitable dimensions. For example, it may have an outer diameterof approximately 10-40 mm, approximately 20-30 mm, or the like.Similarly, it may have any suitable length. For example, it may have alength of about 5 mm to about 50 mm, about 10 mm to about 20 mm, or thelike. In some variations, the balloon has an outer diameter ofapproximately 20-30 mm, and a length of about 20 mm.

The expandable member (in this variation, shown as an expandableballoon) is inflated to position and stabilize the left atrialappendage, as shown in FIG. 14C. In its expanded state, the expandablemember helps locate the ostial plane of the left atrial appendage.Specifically, when the expandable member is expanded, the left atrialappendage is distended and its shape is changed from roughly conical toroughly spherical, thus better defining the junction between the leftatrial appendage and left atrium. In addition, the expandable member inits expanded state may be at a pressure much greater than that of theleft atrium proper, resulting in a significant differential in tensionbetween the left atrial appendage and the left atrium. The expandablemember may have one or more apertures therethrough for passage ofcontrast to facilitate visualization.

While the expandable member is still in its expanded state, a closureelement (1410) of a closure device (1408) may be placed around the leftatrial appendage and closed as shown in FIG. 14D. However, in somevariations, the closure element is placed around the left atrialappendage while the balloon is in its deflated or unexpanded stated, andthen the balloon is expanded. A suture may then be deployed from thedevice, tightened around the closed appendage, released from the device,and severed, leaving the closed appendage in place. Of course, in someinstances it may be desirable to confirm proper closure of the appendageprior to tightening of the suture, and then again after the suture hasbeen tightened using fluoroscopic or other visualization techniques. Ifclosure is not adequate or otherwise not desirable, the loop may beopened, repositioned, closed, and then confirmed once again.

Specifically, it is desirable that the left atrial appendage be closedoff as close to the anatomical ostial plane as possible (i.e., theopening that separates the left atrium from the left atrial appendage).If the left atrial appendage is closed off above the plane of theorifice (toward the left atrial appendage tip or away from theanatomical ostial plane), this may result in a persistent diverticulumof the left atrial appendage, which in turn may result in an additionalsite or nidus for thrombus formation despite complete exclusion of theleft atrial appendage from the left atrium. In some individuals, thegeometry of the left atrium and left atrial appendage may be such thatthe neck or narrowing between them is poorly defined from theepicardial, or outer aspect. In addition, the external geometry of theleft atrial appendage-left atrial junction is difficult to differentiatefrom an epicardial perspective. This may be compounded by the fact thatthe anatomy is moving vigorously when the procedures are employed whilethe heart is beating and the lungs remain inflated (i.e., closed chestprocedures). From an inside aspect, or endocardial view, fluoroscopy andultrasound methods provide limited information or ability to landmarkthe true three-dimensional characteristics of the anatomic ostial plane.Thus the use of the devices described here help facilitate properpositioning and closure of the left atrium, and may be used duringbeating heart procedures, thus resulting in significant advantages overknown left atrial appendage closure devices.

Of course, many variations on this method are possible. For example, theguides may be used as guidewires or rails for additional devices toslide over, or the guides may be coupled to the devices described justabove. Additional guides or guidewires tray also be used, andconfirmation steps may be used throughout as appropriate. The guideshaving the alignment members thereon may be used or removed during themethods as appropriate or desirable. In some variations, the closuredevice has one or more bends or curves along its length, and a tipstraightener or straightening tube is used to temporarily straighten thebend during advancement of the device into the pericardial space. Inother variations, where the device includes a straight elongate body, apre-curved device may be used to aid in delivery after proper access hasbeen obtained. In some variations, the suture loop is made from abiodegradable material and is configured to biodegrade after sufficienttime has passed to ensure scarring or formation of new tissue thateffectively seals of the appendage.

B. Transseptal or Pericardial Access

In the methods described just above, access to the left atrial appendagewas obtained both from inside and outside the heart. Of course, the leftatrial appendage may be closed off using the systems and devicesdescribed here without performing both access procedures as describedabove. For example, in some variations the methods comprise advancing afirst guide having a proximal end and a distal end into the left atrialappendage, through the left atrial appendage, and out of the left atrialappendage, such that one of the proximal or distal ends is within thevasculature, and one of the proximal or distal ends is within thesubthoracic space.

Once access has been obtained in this fashion, a closure device may thenbe advanced into the pericardial space and adjacent to the left atrialappendage, and the left atrial appendage closed off. Of course, theproximal end of the first guide may be within the vasculature, or may bewithin the subthoracic space. In some variations the closure element isadvanced into the pericardial space over the first guide. In othervariations, these methods further comprise advancing a second guide intothe left atrial appendage, where the second guide comprises anexpandable member. The second guide may be advanced to the left atrialappendage over the first guide, though need not be advanced in such afashion.

Other methods of closing the left atrial appendage without performingboth access procedures (i.e., transseptal and epicardial) are alsodescribed here. In general, these methods comprise accessing the insideof the left atrial appendage from the epicardial space, using a devicethat is configured to puncture the appendage wall. An expandable member,such as a balloon, is then advanced through the puncture and into theleft atrial appendage and inflated to help position the left atrialappendage while it is being closed off.

Making reference now to the figures, FIG. 15A shows a left atrialappendage closure device (1500) being advanced adjacent to the leftatrial appendage (1502) from the outside of the heart. The closuredevice may be advanced in any suitable fashion. For example, it may beadvanced via a subthoracic approach, or via intercostal or intracostalaccess, via open surgical access, or the like, as described above. Theclosure device comprises a closure element (1504) (e.g., a loop as shownin FIG. 15A) that is advanced over the left atrial appendage (1502) andtightened to close off the appendage. The device may comprise a blade orother cutting mechanism (1506), and such mechanism may be used topuncture the left atrial appendage after it has been closed, so thataccess may be obtained to the inside of the appendage as shown in FIG.15B. Once access to the inside of the appendage has been obtained, anexpandable member (which may be part of the closure device or be adifferent device meant to cooperate with the closure device) may beexpanded within the left atrial appendage for positioning and such asdescribed above. The left atrial appendage may then be closed off again(and confirmed with the visualization techniques described above), and asuture deployed to permanently fix the left atrial appendage in itsclosed position. The device (1500) may then be withdrawn proximally, andthe suture (1510) severed using any of the techniques described above.An illustrative device (1512) for accomplishing this method is shown inFIG. 15E. Shown there is device having a proximal end (1513) and adistal end (1515), balloon (1514), retractable blade (1520), bladeactuator (1516), and inflation lumen (1518) for inflating the balloon.Of course other suitable devices may also be used to accomplish thismethod.

III. Systems

Also described here are systems for closing a left atrial appendage. Ingeneral, the systems may comprise a closure device useful for performinga left atrial appendage closure procedure as described above, togetherwith one or more additional components. For example, the system maycomprise a first guide having a size and length adapted for accessingthe left atrial appendage through the vasculature and comprising analignment member, a second guide having a size and a length adapted foraccessing the pericardial space from a subthoracic region and comprisingan alignment member, and a closure device. The alignment member may beany suitable alignment member. For example, the alignment member maycomprise radiopaque or echogenic markers, members configured to producean audible response, one or more interconnecting members, one or morevacuum members, or magnets. In some variations, the alignment members ofthe first and second guides comprise magnets as shown in FIGS. 13A and13B respectively.

The closure device may be any of the closure devices described above.For example, the closure device may be one having a closure element thatcomprises a loop defining a continuous aperture therethrough. The systemmay further comprise an expandable member or a device comprising anexpandable member. The expandable member may be any suitable expandablemember, such as, e.g., the balloon catheters described above. Theexpandable member may have one or more apertures therein for allowingcontrast or other fluids to pass therethrough. The system may furthercomprise a suture loop, and the suture loop may or may riot be coupledor couplable to the closure device.

The systems may also comprise one or more devices for severing thesuture. Similarly, the systems may also comprise one or more devices fortemporarily straightening one or more curves along the elongate body ofthe closure device. Of course, the device may comprise instructions forusing any, all, or a portion of, the system components (e.g., firstguide, second guide, closure device, straightening tube, suture cutter,or some combination thereof).

Although the foregoing invention has, for the purposes of clarity andunderstanding been described in some detail by way of illustration andexample, it will be apparent that certain changes and modifications maybe practiced, and are intended to fall within the scope of the appendedclaims.

What we claim is:
 1. A method of closing a left atrial appendagecomprising: advancing an elongate body comprising a lumen therethroughto the left atrial appendage; expanding a closure assembly beyond adistal end of the elongate body, the closure assembly comprising asupport having a first end, a second end, and a loop with an apertureformed between the first end and the second end, wherein the supportcomprises a lumen extending between the first end and the second end andaround the aperture, and a closure loop releasably housed in the lumenof the support; advancing the closure assembly to encircle the leftatrial appendage; closing the closure assembly around the left atrialappendage; retracting a proximal end of the closure loop to release theclosure loop from the support; and closing the left atrial appendage. 2.The method of claim 1, further comprising confirming closure of the leftatrial appendage.
 3. The method of claim 1, wherein the elongate body isadvanced under visualization.
 4. The method of claim 1, wherein theelongate body is advanced from a sub-xiphoid approach.
 5. The method ofclaim 1, wherein the closure assembly is at least partially disposedwithin the lumen of the elongate body during advancement.
 6. The methodof claim 5, wherein expanding the closure assembly comprises advancingthe closure assembly distally through the lumen of the elongate body. 7.The method of claim 1, wherein advancing the elongate body to the leftatrial appendage comprises advancing the elongate body through a lumenof a guide sheath.
 8. The method of claim 1, wherein the support furthercomprises a second lumen.
 9. The method of claim 1, wherein the closureloop comprises a suture loop.
 10. The method of claim 1, whereinexpanding the closure assembly comprises increasing a size of theaperture of the loop.
 11. The method of claim 1, the closure assemblyfurther comprising a closure element.
 12. The method of claim 11,wherein a portion of the closure element is housed within the support.13. The method of claim 1, wherein the elongate body houses a suturehook coupled to the closure loop.
 14. The method of claim 1, wherein aproximal end of the elongate body is coupled to a handle.